Chest Trauma

Extension of cancerous lesions

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the MOST likely cause of the pleural effusion?

Remove the air that is present in the intrapleural space

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?

Keep collection device below the level of the client's chest

A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do?

Rapid, thready pulse Decreased blood pressure

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply.

Emptying. the bladder immediately before the procedure

A healthcare provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan?

Pulsus paradoxus Muffled heart sounds Jugular vein distention

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply.

Comparison of chest radiographs

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube?

Restores negative pressure in the pleural space

A nurse is caring for a client with a history of COPD who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care?

Hypovolemic shock

A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for what reaction?

Constant bubbling in the water-seal chamber

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Prepare for needle thoracostomy

The nurse is caring for a client with breathing difficulty and is unable to auscultate any breath sounds on one side. Which action should be implemented first by the nurse?

Extreme fatigue Coughing at night Difficulty breathing

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.

The nurse should monitor the vital signs, especially the pulse. The nurse should maintain vascular access with a large-bore catheter

What are the primary nursing interventions to check the circulation in a client? Select all that apply.

Shortness of breath Unilateral chest pain

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply.

Decreased filling of the right side of the heart

When a client suffers a complete pnuemothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause of concern?

Muffled heart sounds Cardiac output 2.8 L/min Central venous pressure 20 mmHg Pulmonary artery diastolic pressure of 30 mmHg

Which assessment data will the nurse interpret as a sign of cardiac tamponade? Select all that apply.

Trachea deviated to the left

Which assessment data would the nurse anticipate for a patient with a right lung pneumothorax?

An increase in bloody chest tube drainage

Which assessment finding would cause the nurse to suspect a life-threatening complication following a lung resection?

Intrapulmonary shunting develops

Which pathophysiology process is associated with a pneumothorax?

15-30 mmHg

Which range reflects pulmonary artery systolic pressure?

Palpate the surrounding area for crepitus

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?

Pulmonary artery

Where does the pulmonary circulatory system begin?

Absent breath sounds

Which abnormal breath sound would the nurse associate with a pneumothorax?

Rises in the tube of the water-seal chamber during inspiration

Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly?

Class II

According to WHO Functional Classification of Pulmonary Hypertension, which class is indicated when a patient gets SOB while walking to the bathroom but recovers quickly with rest?

Check the system for air leaks

After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the nurse do?

Preparing to intubate Preparing for needle thoracostomy and chest tube insertion

During a fire, a large group of people suffocate sue to smoke inhalation and are immediately admitted to the emergency unit. The assessment findings in these clients reveal absent breath sounds. Which nursing interventions are appropriate in this situation? Select all that apply.

Check the tube to ensure that is not kincked

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What INITIAL action should the nurse take?

Continue to monitor the drainage

For a patient immediately post-heart-lung transplant, which action would the nurse take when a chest tube has blood drainage of 80 mL at 0900; 100 mL at 1000; and 80 mL at 1100?

Jugular venous distention

For which condition in a postoperative cardiac patient will the nurse monitor for signs of cardiac tamponade?

Atelectasis Bronchiectasis Pneumonia with consolidation Pneumothorax

For which lung condition would the nurse anticipate less chest motion on the affected side? Select all that apply.

White blood cells from an infection

For which reason would a patient's CSF appear cloudy?

Rises with inspiration and falls with expiration

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?

Reduced or absent breath sounds at the base of the lung

What should the nurse expect when assessing a client with pleural effusion?

Cardiorenal syndrome (CRS)

Which condition is caused by ARBs in a patient with heart failure?

Closed

Which type of pneumothorax will the nurse anticipate in a patient who experiences blunt chest trauma?

Diminished breath sounds on the affected side

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs?

A chest x-ray will be performed to determine lung re-expansion

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of?

Instruct the client to splint the wound with a pillow when coughing

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?

Ensure the security of the connections from the client to the drainage unit

A client who had thoracic surgery is admitted to the PACU. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system?

Prevents reflux of air back into the chest

A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water?

Apply a wound dressing

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's FIRST action?

It removes air from the pleural space

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube?

Ensure patent airway

A client with chest trauma is admitted in the emergency department. Which intervention takes priority?

Rupture of a subpleural bled

A client with emphysema experiences a sudden episode of SOB and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what LIKELY cause of the spontaneous pnuemothorax?

Apply a petroleum gauze dressing over the site

A client's chest tube has accidentally dislodged. What is the nursing action of HIGHEST priority?

Air in the pleural space communicates with air in lungs only on inspiration; air pressure in pleural. space is greater than atmospheric pressure

Which description reflects a tension pneumothorax?

"You should expect to be sitting in a chair the day after surgery." "Incentive spirometry is very important and will be encouraged hourly after surgery." "you will likely have a chest tube following the surgery." "Splinting can be very helpful to decrease pain, especially with deep breathing and coughing."

Which instruction will the nurse give a patient who is undergoing thoracic surgery? Select all that apply.

Pleural effusion Pneumothorax

Which lung condition is associated with inspiration greater than expiration lung sounds? Select all that apply.

Immobilizing the cervical spine Preparing for chest tube insertion Applying direct pressure to a wound

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply.

Pulmonary hypertension

Which term reflects progressive narrowing of the small pulmonary vessels resulting in an increase in pulmonary vascular resistance?

Absence of breath sounds on auscultation

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?

Empty the bladder before the procedure

A HCP schedules a paracentesis. What should the nurse intact the client to do to prepare for the procedure?

Palpating the neck or face

A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. What assessment by the nurse is the BEST method for assessing this complication?

Mark the time and fluid level on the side of the drainage chamber

A client is admitted to the post-anesthesia care unit after a segmental resection of the right lower lobes of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?

Air will move from the lung into the pleural space

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?

Administer oxygen as prescribed

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do FIRST?

Increased breath sounds

A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment?

Keep the drainage system lower than the level of the client's chest

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is CORRECT?

Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side

A nurse on the disaster management team is caring for survivors of an earthquake. The nurse understands that some survivors may have chest trauma and may need a needle decompression to relieve the air or fluid trapped in the chest. Following the initial assessment, which client would the nurse treat first?

Extract peritoneal fluid Improve respiratory status Obtain peritoneal fluid for culture

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? Select all the apply.

Mediastinal shift

After a lateral crushing chest injury. obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client?

Hypercapnia

After a spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increase. What do these client responses indicate to the nurse?

"I get a sharp, stabbing pain when I take a deep breath."

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

HR increases from 80 to 135

During a client's paracentesis, 1500 mL fluid is removed. The nurse monitors the client for which sign of a potentially severe response?

Verify breath sounds Encourage deep breaths Ensure a chest x-ray is performed after the procedure

The primary HCP is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracenteses? Select all that Apply.

Innervation of the phrenic nerve

When a pericardial effusion occurs, which condition causes the associated pain to the patient?

Cardiac tamponade

Which condition is a mechanical etiology of cardiogenic shock?

Pneumothorax Pleural effusion Complete airway obstruction

Which condition is associated with absent breath sounds? Select all that apply.

Refer to the date and time markings on the outside of the collection chamber

A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage?

Decreased cardiac output because of mediastinal shift

A client has a right upper lobectomy to remove a cancerous lesion. After the surgery, the nurse monitors the client for the MOST life-threatening complication, which is what?

Quality and depth of respirations

A client is admitted to the emergency department with a stab wound to the chest. What is the PRIORITY when the nurse performs a focused. assessment of the client's response to this injury?

Observe for fluctuations of the fluid in the water-seal chamber

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a. chest tube to a closed. chest drainage system. What should the nurse do to determine if the chest tube is patent?

Obtaining equipment for chest tube insertion

A nurse is notified that a victim of a GSW to the right side of the chest is being transported to the emergency department. To prepare for the client, what is the PRIORITY nursing intervention?

Keep a bottle of sterile water at the bedside

The nurse includes which intervention when creating a plan of care for a patient with a chest tube to water seal suction?

Weight gain

The nurse instructs the client admitted for an acute exacerbation of COPD about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for?

Disability

The nurse is reassessing level of consciousness and mental status in a client who survived a fire. Which type of emergency assessment of the trauma client is the nurse performing?

Document 150 mL of chest tube drainage Assess bloody drainage in the chest tube system Attach chest tube to wall suction Milk the chest tube to remove clots

Which action will the nurse take when caring for a patient with a chest tube who is 2 hours post-thoracic surgery? Select all that apply.

Tamponade Bleeding

Which reversible cause would be assessed in a postoperative cardiac patient who has arrested and shows pulseless electrical activity? Select all that apply.

Pneumonectomy

Which thoracic surgery is used to remove an entire lung?

Hemopneumothorax

Which type of condition does the nurse anticipate in a patient whose diagnostic testing shows air and blood in the pleural space?

Hemothorax

Which type of condition does the nurse anticipate in a patient whose diagnostic testing shows blood in the pleural space?

Right ventricular failure

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing?

Collect drainage

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider?

Bronchial obstruction or pleural effusion

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. What does the nurse conclude is the probably cause of the severe dyspnea?

Negative pressure in the pleural space

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished?

Encourage range of motion to the client's arm on the affected side

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client?

Rapid removal of large amounts of fluid may precipitate cardiovascular collapse

A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include?

Neck vein distention

The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect to observe if this occurs?